Bulletin of Rehabilitation MedicineBulletin of Rehabilitation MedicineВестник восстановительной медицины2078-19622713-2625National Medical Research Center for Rehabilitation and Balneology62608610.38025/2078-1962-2023-22-5-83-92ArticlesСтатьиReview ArticleLow Back Pain: a New Comprehensive Pathogenetic Model Supporting Methods of Medical RehabilitationБоль в пояснице: новая комплексная патогенетическая модель, подкрепляющая методы медицинской реабилитацииhttps://orcid.org/0000-0003-0980-1587TesioLuigiТезиоЛ.
Italy

Dr. Sci. (Med.) Director, Department of Neurorehabilitation Sciences

l.tesio@auxologico.itIstituto Auxologico ItalianoИтальянский Ауксологический Институт15112023225839226012024Copyright ©; 2023, Tesio L.Copyright ©; 2023, Тезио Л.2023Tesio L.Тезио Л.https://creativecommons.org/licenses/by/4.0https://journals.eco-vector.com/2078-1962/article/view/626086

The pathogenesis of chronic low back pain remains elusive. It is still considered a «non-specific» condition, with severity loosely related to anatomical alterations of the lumbar spinal canal (e.g., disc herniation, spinal stenosis). Signs and symptoms may appear contradictory, such as pain aggravated by rest or spinal loading, opposite lumbar postures (flexed or extended) adopted by different patients, and others. Guidelines and reviews oscillate between a restrictive nerve compression model to large sets of epidemiologic factors (from lifestyle to chronic lumbar stress to genetic determinants). A new pathogenetic model is presented here, based on the variable interaction between three possible determinants: compression of nerve endings by disc herniation or arthritic spurs, engorgement of the epidural (Batson) venous plexus, and inflammation triggered by focal thrombophlebitis and fostered by fibrinolytic defects. Hence, the name Compressive-Venous-Inflammatory (CoVIn) is given to the model. Biological and clinical studies provide evidence for each of the three cited determinants. The integrated model explains many «unexplained» characteristics of LBP and provides a rationale for mechanical treatments targeting one or more of the three determinants. Active Lumbar Traction (auto-traction), water exercise, and Williams’ flexor exercises look highly consistent with the model, which can explain their effectiveness.

Патогенез хронической боли в пояснице остается неясным. Она до сих пор считается «неспецифическим» состоянием, выраженность которого слабо связана с анатомическими изменениями поясничного отдела позвоночного канала (например, грыжа диска, спинальный стеноз). Признаки и симптомы могут быть противоречивыми, например, боль, усиливающаяся в покое или при нагрузке на позвоночник, противоположные позы в поясничном отделе (сгибание или разгибание), принимаемые разными пациентами, и др. Руководства и обзоры колеблются между ограничительной моделью компрессии нерва и большим набором эпидемиологических факторов (от образа жизни до хронического поясничного стресса и генетических детерминант). Новая патогенетическая модель основана на вариабельном взаимодействии трех возможных детерминант: компрессии нервных окончаний в результате грыжи диска или артритных шпор, ущемления эпидурального (по Бэтсону) венозного сплетения и воспаления, вызванного очаговым тромбофлебитом и способствующего развитию фибринолитических дефектов. Отсюда возникло название «компрессионно-венозно-воспалительная» (CoVIn) модель. Биологические и клинические исследования подтверждают наличие каждой из трех указанных детерминант. Комплексная модель объясняет многие «необъяснимые» характеристики боли в пояснице и дает обоснование для механических методов лечения, направленных на одну или несколько из трех детерминант. Активное вытяжение поясницы (ауто-тракция), водные упражнения и упражнения Уильямса на сгибание выглядят в высшей степени соответствующими модели, что может объяснить их эффективность.

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